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A nurse in a busy outpatient ob/gyn center is assessing a new client.
After performing a set of vitals and obtaining her weight, she turns to the woman and asks, "What type of birth control are you using?"
"The Creighton Model," the woman replies.
The client then proceeds to pull out a 9 1/2 by 11-inch folded piece of paper with multicolored stickers and cryptic notes on it, and explains she has been utilizing it for 3 years.
She says she recently noticed her biomarkers have changed and asks the nurse, "Are there any doctors in this practice who are trained in NaPro?"
Sound improbable?
From the ADVANCE Archives
Situations such as these are expected to occur more frequently with the growth of restorative reproductive medicine (RRM), an approach that seeks to cooperate with and/or restore the normal physiology of the human reproductive system.
One of the most popular RRMs is Natural Procreative Technology, also known as NaPro Technology, NaPro and NPT.
While unfamiliar to many nurses, NaPro relies entirely upon information obtained from the client's ovulation observations and charting utilizing a system known as the Creighton Model FertilityCare System (CrMS).2
Birth of CrMS
CrMS is rooted in research of the Billings Ovulation Method, a natural family planning method which relies on cervical mucus observations.
CrMS took its name in 1977 when the principal investigator, Thomas W. Hilgers, MD, joined the newly established Creighton University Natural Family Planning Education and Research Center at the Creighton University School of Medicine in Omaha, NE.
In 1985, Hilgers, a clinical professor at Creighton, founded the Pope Paul VI Institute for the Study of Human Reproduction, also in Omaha.
CrMS relies upon the observation of bleeding patterns, cervical mucus and cycle lengths, which are referred to as biomarkers. These biomarkers indicate to the woman if she is ovulating, when she is ovulating and weather the process is normal. The biomarkers become a diagnostic tool for the specially trained physician or other healthcare provider.1
Women are taught how to record the biomarkers and are recommended for treatment when they fall outside of an established norm. If a problem is identified, it is treated with NaPro's medical and surgical protocols that complement the woman's fertility or menstrual cycle.1
Learning the System
CrMS is taught by allied health professionals known as Fertility Care Practitioners (FCP) who are listed on the website http://www.fertilitycare.org/.
While criticized by some who consider it too time-consuming with a long learning curve and multiple follow-ups, CrMS has an 89 percent continuation rate, one of the highest of any birth control method.3
Women interested in CrMS first enter a certified program of instruction by attending an introductory session followed by a series of one-on-one follow-up appointments with their FCP.
 The session is typically a power point or slide presentation and is considered the first step to learning the method. At the end of the introduction period, the woman and/or couple decide if they wish to utilize the system. Course materials are provided and the client is urged to begin charting immediately.
Follow-ups are scheduled 5 times during the first 3 months, and an additional 3 times over 1 year.
A successful user of the system will make accurate observations, record them on her chart and follow the instructions according to her intention.
Health & Fertility
Women who choose to use CrMS are taught how to identify the characteristics of cervical mucus and how to use this knowledge to not only plan families naturally but also monitor and evaluate their gynecological health.
Much of the focus in the instruction involves the woman identifying what is called the peak day. This day is the closest marker to ovulation there is outside of observing real-time eruption of the Graafian follicle.
The mucus days prior to the peak day and for 3 full days afterward are considered fertile by the system as it has been documented that sperm can survive in the presence of cervical fluid for up to 5 days.
The days of uterine bleeding in addition to menstruation are also recorded, especially unusual bleeding, which is brown or black in appearance. Clients need to pay particular attention to when it appears in the cycle.
Charting the cycle allows the specially trained NaPro physician, nurse practitioner or midwife to conduct a more complete evaluation by the client. They are able to identify abnormal patterns such as irregular bleeding and poor cervical mucus flow - symptoms that are often not detected by routine gynecologic evaluation.4
Wide Appeal
RRM appeals to women for a variety of reasons. Conditions such as endometriosis, polycystic ovarian disease and hormonal dysfunctions are often the underlying causes of infertility and repetitive miscarriage.
Some clients are health conscious and wish to have less chemical and invasive means to plan their families. Others may wish to utilize it for moral or ethical reasons. There are even those who are seeking alternatives to conventional medicine.
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Additionally, many women have reported being dissatisfied with answers from their doctors to their infertility questions before discovering the root of the problem when they found a healthcare provider trained in NaPro Technology and began charting.5
In 2009, a study in the Journal of American Board of Family Medicine concluded that NaPro had live birth rates comparable to cohort studies of more invasive treatments, including assistive reproductive technology.
Of the 1100 couples who sought medical help to conceive using NaPro, 52.8 percent of those completing treatment could expect to have a successful live singleton birth.
The NaPro result was even more surprising given that one-third of these women had already failed IVF and had tried longer to have a baby. For women who hadn't tried IVF prior to NaPro, the birth rate was 61.5 percent.6
Nursing Considerations
The ideal candidate for CrMS instruction is a woman committed to the idea of a more natural approach to reproductive health and fertility.
Women diagnosed as infertile may find NaPro more effective than IVF at a fraction of the cost without embryo cryopreservation and storage. Women who utilize CrMS may find they have to pay for instruction, as many FCPs are independent providers, and as such do not receive third-party reimbursement. This is expected to change as two new ICD-9 codes allow for reimbursement, leading more medical practices to hire FCPs.
Nurses should keep in mind, however, that an individual's motivation and support should be considered before a referral is made to a FCP. Nurses should also remind clients that while the NaPro infertility program is one of the most successful, a pregnancy can never be guaranteed. Referrals to infertility support groups, especially those focused on natural conception, are of great help to women at this time.
By educating themselves about CrMS, nurses can assist women in making informed choices that will have a positive effect their future fertility and their families.
References for this article can be accessed here.
Barbara Savinetti-Rose is the American Academy of FertilityCare Professional's "Outstanding FertilityCare Practitioner of 2011."
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